Healthcare Provider Details

I. General information

NPI: 1275517013
Provider Name (Legal Business Name): GLENN C HENRIKSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

541 OTIS BOWEN DR
MUNSTER IN
46321-4158
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036063101
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: